Otis and the EarAche

Otis is a typical 9 year old boy. I realize that is awfully judgy of me, having just known about him for minutes... but I've become pretty good at recognizing key features of patients. For example, I say he's typical because he has two hands and two ears and he wears pants.

He came with his mother to our clinic because one of those darn ears just wouldn't stop hurting. And for good reason. Looking in the ear, my colleague, Vanilla, saw a nasty looking otitis media, an infection of the middle ear. His eardrum looked like a mini cherry tomato.

Open and shut case.

Vanilla prescribed some antibiotics and analgesics and the boy with two ears left.

Three weeks later, Otis came back again, still wearing pants. And still complaining of right ear pain. This time, a peek through the otoscope showed something completely different.

And more worrisome.

His external canal, the hollow tube running from the outside of the ear to the ear drum, was filled with pus. The cherry tomato had popped, spilling pent-up infection into the narrow tunnel. The mother explained that she had not picked up the antibiotic prescription. This didn't surprise Vanilla. It has become a tune we hear all too often these days. So Vanilla cultured the drainage, encouraged the mother to get the medicine (which she agreed to) and the boy with two ears left.

72 hours later, Otis and his mother returned for follow-up. Otis was feeling more miserable, feverish, growing Pseudomonas (learned from the culture result) and still had not taken any antibiotics. Why?

The mother, embarrassed and concerned, confided that she simply couldn't afford the medicine.  Not then. Not now.

Vanilla then came into my office with a dilemma. Here is a minor, hurting, at the mercy of his mother's poverty and lack of resources. We both expressed concern about not only the child's acute suffering, but potential complications of an untreated infection, including hearing loss. This 9 year old typical boy could be on the cusp of turning atypical: with two hands and one ear.

"I want to pay for the boy's antibiotics," she told me. "Should I?"

There are compelling reasons to do it.

And not to do it.

What would YOU do?

Ukelele and Jesus

Ukelele, as I am going to call her, was strumming along as well as could be expected for a 76 year old widow. Fairly healthy, except for Type II Diabetes, she first came to see me to establish care at our new clinic, which was closer to her home.

A month later, Ukelele thought she was getting Alzheimer's disease, complaining of short term memory loss manifested mostly with forgetting names and misplacing things. I named three objects and asked her to repeat them. Five minutes later, I asked her to repeat those three objects, which she did easily, grinning like a fourth-grade spelling bee winner when she got them right. (I, too, breathed a sigh of relief that I remembered them.)

She passed all of the other components, too, of the mini-mental state examination (MMSE), a screening test used to identify memory and thought impairment. Even more importantly, she drew a clock with clock-like precision, spacing the numbers evenly in circumference. Those with dementia, and forms of hemispatial neglect, typically draw the numbers of the clock bunched on one side. She denied any hint of urinary incontinence.

Whatever she had, it probably wasn't dementia.

Then Ukelele said something which caught my attention.

"When I come to your office or the grocery store, I can remember things perfectly."

Suddenly, I had a clearer understanding of where this conversation and probable diagnosis was heading.

"Tell me about life at home," I queried.

She began to tell her story while I listened, intently, a therapeutic measure in and of itself. She was struggling with financial pressures, missing her husband, and feeling overwhelmed with home repairs and upkeep.

Then, after scoring moderately high on the Geriatric Depression Scale, I presented the idea of depression as a possibility for her memory impairment. We both agreed to try a low dose anti-depressant medication to tackle this.

One month later, she presented for follow-up. Her eyes were wide and bright as she reported,

"I am slowly starting to remember where I put things.... I am sleeping better and not so sad."

Her serotonin-induced improvement incited a dopamine surge for me. I was genuinely happy she was feeling better.

"My knee hurts" she then abruptly changed subjects.

More questions, a knee exam, followed by an x-ray dappled with osteophytes gave me reassurance that she was suffering from the inevitable wear of aging on the joint cartilage: osteoarthritis. Though painful, it is usually not as destructive, nor require toxic medicines as does the pesky cousin: rheumatoid arthritis. This was good news. When I told Ukelele I thought she had arthritis, she clapped her hands in the air, raised her head to the ceiling and squealed,

"Thank you, Jesus!"

She continued, "I have been praying to Jesus that you would say that."

Then she grabbed my hands. "And I have been praying to Jesus, every day, for YOU."

Oh....I thought. What a sweet thing to say, Ukelele. Music to my ears, really.

Because, as God knows, I need it.

We all do.

To Believe or Not

She came in all spruced up, hair curled, make-up just right. She carried herself well with perfect posture. Except for the curious scars on her left cheek, her complexion was flawless. At first impression, I thought her story was going to be a little more positive than most of the stories I hear day in day out.

My hunch was debunked about 2 sentences into our conversation.

She wanted Alprazolam (Xanax)... a highly addictive drug, which can net sellers upwards of $5 per pill on the streets. It is a medicine I choose not to prescribe, because you know... the rotten few have ruined it for the deserving many.

Before turning Cindy away, I listened, disheartened, as she told me her story. She had been locked away in a tiny room, a prisoner in her own home, with very little food and no sunshine. The jailer was her husband, who had gradually become more abusive, at one point smashing her face and fracturing her left cheekbone. At his breaking point, he threw Cindy in a bedroom, locked the door, and she wouldn't see the light of day for 9 months. He had become her sole source of  food, freedom and fear.

After Cindy's daring escape, she began to have nightmares and anxiety, developing classic symptoms of post-traumatic stress disorder. She was prescribed Xanax to fight her fires, which helped her cope and quenched the flames. She began to help other women with similar stories, and soon became a model of strength, a pillar of support for others. Reaching outwardly helped her heal inwardly. Eventually, she was hired as the director of a local goodwill organization, and she felt strong enough to wean from the Xanax, another captor from which she wanted to escape.

But slowly, her nightmares and flashbacks re-emerged, the embers re-igniting. For the last 6 months, she had embattled the discomforts with stoicism, but finally accepted the need for extrinsic help. She wanted... needed the medicine to cope.

So she sat in my office, crying, hoping for a prescription.

Her story was compelling. It sounded legitimate. Her external scars glaring proof of something gone awry. I told her that I don't prescribe that medicine, but would refer her to our in-house psychiatrist who could give her that, or something more effective. She cringed under the weight of the inevitable wait.

Maybe her store is true, every word. Maybe she is the exact person for whom this medicine is designed for. Maybe she deserves this med, whenever she needs it.

And maybe.....she told me a darn good story, and has developed a Streep-like ability to cry when the moment is right.

I'll never know. She has never returned.

But I have returned again and again to thinking about that experience.

And it haunts me, did I do the right thing?